CHICAGOThe decisions doctors make regarding breast cancer care
vary widely, as do the guidelines that these doctors may reference when making
treatment decisions. Speaking at the Robert H. Lurie Comprehensive Cancer
Center of Northwestern University’s annual Health Policy Symposium, Stephen
B. Edge, MD, of Roswell Park Cancer Institute and the State University of New
York-Buffalo, discussed several breast cancer practice guidelines and the means
by which they can become most useful.
Dr. Edge said that variations in treatment practice do not necessarily
translate into variations in quality of care. Guidelines can facilitate
evaluation of the quality of care by comparing actual treatment of a specific
patient with a set practice guideline. This enables providers to prove to
insurers the effectiveness of their treatments and provides useful data for
quality assessment of individual physicians and medical facilities.
For these guidelines to be of most use, Dr. Edge argued that they must be a
part of a program that improves quality, cost-effectiveness, and outcomes. He
reviewed five comprehensive guideline program efforts, each focusing on
different aspects of the disease and varying in scope.
- Ontario Cancer Treatment Practice Guidelines Initiative, one of the
first comprehensive guidelines developed, addresses several specific clinical
- Revlon/UCLA Breast Cancer Guidelines provide standards for diagnostic
evaluation of suspicious findings, treatment of primary and recurrent disease,
and adjuvant systemic therapy.
- Society of Surgical Oncology Guidelines provide standard approaches
to the evaluation of symptoms, abnormalities, and surgical treatment of breast
cancer. Association of Community Cancer Centers (ACCC) guidelines offer
standards for initial staging, management of local disease, and adjuvant
systemic therapy of early-stage disease.
- National Comprehensive Cancer Network (NCCN) guidelines address all
aspects of treatment after diagnosis, including stage workup, local therapy,
adjuvant systemic therapy, follow-up care, and treatment for recurrent disease.
One of the main challenges of practice guidelines is how to appropriately
revise and incorporate innovations in the standard of care. Such revision is
essential to keep the guidelines current. The guidelines reviewed above employ
a variety of methods for revision and re-evaluation.
In addition to regular updating, there must be an ongoing evaluation of a
guideline’s utility for its targeted audience. Efforts aiming at addressing
the usefulness of guidelines include retrospective comparisons of actual
practice to published standards, examination of the effect of published
guidelines on actual practice by reviewing data before and after the time the
guidelines were published, and the measurement of practice standards and
comparison to an individual physician’s practice.
Dr. Edge argued that the ultimate goal of such studies will be to assess
whether the use of guidelines improves patient outcomes. Unfortunately, due to
the complexity of breast cancer care, the use of the guidelines mentioned above
has not yet been shown to improve outcome.